Stress & Trauma Toolkit

for Treating Asian Americans in a Changing Political and Social Environment

Asian Americans are often perceived as a single homogeneous group; however, this population of 21 million people consists of more than 28 subgroups with multiple languages, religions, cultures, and socioeconomic backgrounds. The latest U.S. Census Bureau reports indicate that Asian Americans have the fastest population growth rate of any major racial or ethnic group in the United States . Asian Americans experience rates of mental illness similar to that found in other U.S. populations. However, Asian Americans may be less likely than other groups to seek mental health services and support than other racial or ethnic minorities--except in extreme and life-or-death situations. Recent Asian immigrants face many challenges and emotional turmoil as they adjust to a new cultural and political environment.

There are currently 1.5 million undocumented Asian and Pacific Islander (API) immigrants who may fear persecution as U.S. immigration policy evolves in the current political climate. The Deferred Action for Childhood Arrivals (DACA) program, launched in 2012, provided temporary amnesty and access to job opportunities for over 800,000 young undocumented immigrants who grew up in the U.S. Young undocumented APIs report that DACA reduced their fears of legal repercussions for seeking health care services (Building Community Raising API Voices for Health Equity (BRAVE) Study). These DACA recipients also reported feeling overall less distressed emotionally and psychologically than non-DACA recipients when facing common stressors such as fear of deportation, job insecurity, and unpredictable futures for themselves and their families. In general, undocumented API immigrants have an improved sense of well-being and community security with the legal identification provided through DACA. As Congress continues to debate the fate of DACA, providers must consider its impact on the public health of immigrants, including API immigrants.

Clinical Vignette

Mr. Z, 30 years old

Mr. Z is a 30-year-old single man who was born in China. He entered the United States with his parents as an undocumented immigrant in 1998 when he was 10 years old and is now residing in Massachusetts. He has been unable to find steady employment due to his immigration status. He has no health insurance and presents to the emergency room with a report of 6 months of worsening generalized anxiety and frequent panic attacks, irritability, and difficulties in initiating and maintaining sleep.

Mr. Z worries about his ability to remain in the U.S. and has been experiencing suicidal ideation since the DACA program was rescinded, further jeopardizing his future. He fears that this country is becoming less welcoming to immigrants and worries about his prospects for remaining in this country.

Factors that Put Asian Americans at Risk for Mental Health Problems

Racism, racial bias, and discrimination: Racism, racial bias, and discrimination contribute to Asian Americans’ experience of marginalization and alienation. Although many Asian Americans have achieved professional success, they may still encounter barriers preventing them from reaching leadership positions in their respective professions.

Racial stereotypes and profiling: Asian Americans are frequently stereotyped as being smart, hard-working, successful, and eager to enter and blend into American society. However, while many Asian Americans excel educationally and financially, others may struggle. The ‘model minority’ stereotype only exacerbates Asian Americans’ tendencies to not seek help, even in the face of mental illness.

Language barriers: English is not the primary language for some Asian American immigrants. For these, language barriers may pose challenges to acculturation and assimilation into American life. A common example of this occurs when an Asian American is ridiculed, misunderstood, or even bullied as a result of their accent.

Immigration status: The estimated 1.5 million undocumented Asian Americans (represent 14% of all undocumented immigrants in the U.S. They remain in perpetual fear of arrest, deportation, and separation from their families as well as the loss of businesses they have worked hard to build over the years.

Trauma: Immigration leaves people susceptible to trauma in various stages of the migration process. For example, older immigrants may have experienced trauma associated with historical events in their countries of origin such as China’s Cultural Revolution or the Vietnam War.

Low levels of mental health literacy: Some Asian Americans are unfamiliar with Western medical models of mental illness and the availability of effective treatment for several common psychiatric conditions. This knowledge gap leads to under-recognition and delayed treatment of their mental illness.

Stigma towards mental illnesses: Stigma surrounding mental illness may prevent some Asian Americans from admitting to symptoms of mental illness. They are also known to have the lowest rates of mental health service utilization among any racial or ethnic group. Medical literature shows that education about mental health reduces mental health stigma in Asian Americans. Mental illness can be stigmatized by some Asian cultures as a weakness in an individual and/or a collective failing or weakness of the individual’s entire social group.

Varying presentation of symptoms in different groups: Asian Americans may present in primary care settings with somatic complaints for underlying psychiatric conditions. For example, research has shown that a significant number of Asian Americans--including those of Chinese and Indian descent--with depression may present with insomnia and gastrointestinal issues. Insomnia itself may be an early sign of a psychiatric illness, such as post-traumatic stress disorder (PTSD), in Asian Americans who experienced political strife in their countries of origin such as Vietnam and Cambodia.

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Suggested Assessment and Treatment Recommendations

  1. Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  2. Work towards integrated care models: Collaboration with primary care providers is recommended for two major reasons: (1) Asian American patients often express emotional distress through somatic symptoms and (2) Stigmatization of mental illness in Asian American communities makes it unlikely that patients will seek mental health services. Integrated Care Treatment can include routine screening for stress, anxiety, depression, and trauma in primary care settings to help identify patients, connect them to resources promptly, and reduce healthcare disparities.
  3. Provide relevant resources in English and Asian languages: Information or links to online resources about mental illness in both English and Asian languages can be helpful. It is advised not to use family members as translators. If possible, provide information regarding community-based mental health services, health insurance, and immigration policies.
  4. Acknowledge the role of spirituality/religion: When appropriate, address the spiritual dimension of mental health and treatment for Asian Americans. Collaborate with spiritual care professionals in identifying and managing mental health issues.
  5. Pay attention to protective factors: A strong ethnic identity can help protect against mental illness. Encouraging these cultural identities may help build resilience in patients.

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Resources

American Psychiatric Association. Mental Health: A Guide for Faith Leaders. 2015. https://www.psychiatry.org/psychiatrists/cultural-competency/faith-community-partnership

Best Practice Highlights for Treating Diverse Patient Populations: Working with Asian Patients https://www.psychiatry.org/psychiatrists/cultural-competency/treating-diverse-patient-populations/working-with-asian-american-patients/working-with-asian-american-patients

Building Community Raising API Voices for Health Equity (BRAVE) Study website. http://www.thebravestudy.org/

Gaw A. Working with Asian American Patients. American Psychiatric Association website on Cultural Competency. https://www.psychiatry.org/psychiatrists/cultural-competency/treating-diverse-patient-populations/working-with-asian-american-patients

Integrated Care: Learn About the Collaborative Care Model. American Psychiatric Association website. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn

Mental Health and Faith Community Partnership. American Psychiatric Association website on Cultural Competency. https://www.psychiatry.org/psychiatrists/cultural-competency/faith-community-partnership

References

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Authors

  • Enrico G. Castillo, M.D., M.S.H.P.
  • Anish Dube, M.D., M.P.H.
  • Wai Lun Alan Fung, M.D., Sc.D.
  • Jai Gandhi, M.D.
  • Emily Wu, M.D.
  • Albert Yeung, M.D., Sc.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.